HomeMy Public PortalAbout9050 ACASO DR_Building_2/20/1996 cle
`" ' - APPLICATION FOR BUILDING PERMIT
a+.''�' �A.~r COUNTY OF LOS ANGELES BUILDING AND SAFETY
•� WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDPi 6 DRESS'/�
�r BUILDING ADDRESS
hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.) CITY ZIP 0
LOCALITY
Policy No. Company SIZE OF LOT O.OF BLDGS.NOW ON LOT �
❑ Certified Copy is.hereby furnished. NEAREST CR
Ly
❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO.
department. USE ZONE MAP NO.
ASSESSOR MAP BOOK _PAGE PARCEL
Date Applicant A r/! ?i SPECIAL CONDITIONS —O/
CERTIFICATE OF EXEMPTION FROM WORKERS' !d N/ (s VES NO
COMPENSATION INSURANCE OWNER C� �� TSL O. � �� WITHIN 1000 FT:OF SCHOOL?
(This section need not be completed if the permit is for one hundred ADDRESS�D „/ f`�v D�,�.11/1
DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY
dollars ($100j or less.)
CITY ZIP .
I certifythat in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to v� / v '�✓
is issued,
le subject shal to theployWorkers'Compensation n a Laws. ARCHI EGT OR
NGINEER TEL NO.
STATISTICAL CLASSIFICATION APT CONDO
Date Applicant ADDRESS CLASS NO. DWELL UNITS'
NOTICE TO APPLICANT If, after making this Certificate Of REQUIRED TOTAL SETBACK FROM EXIST
Exemption, you Should become Subject to the Workers' CONTRACTOR— T NO.` SET BACK YARD HWY PROP LINE WIDTH
Compensation provisions.of the Labor Code, you must forthwith l e �� ��✓ y FRONT
comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL
`
LICENSED CONTRACTORS DECLARATION �— ` 0 3 SIDE O
CITY n�j,� LIC.CLASS PL
hereby affirm that I am licensed underpro ions of Chapter 9 �/� SEWER MAP
(commencing with Section 7000)Of Divisio of the Business and SQ. SIZE N..OF STORIES NO.OF FAMILIES
Professions Code,an my Ijcens is in f force and eff t;, ��j,V� NEW ❑ BK PG O
rj DES TION OF WORK -VALUATION , U.
License Number c.Class / ADD ) W
Contractor Date 6 ALTER 11 $ /%Q o O`00 a_
❑ I am exempt under Sec. REPAIR ❑ $ Z
B.BP.C.for this reaso �� ElLDMA P/C#
D e: USE OF EXIST BLDG. URM ❑
1evvr
Signature APPLICANT(PRINT) TEL iDNA Perm# '•'
YW,47 C/7�D-amu e��� -�3� .23
❑ I, a. own of the pr erty, or my employees with wages as Z •�
their sole Compensa Ion, will d0 the work and the structure is ADDRESS I /N�j r^ • O ;h!II �•i a s
not intended or offered for sale (Section 7044, Business and bV� /�� S6 N� (�l/L '/7 FINAL OAT 'a
c- c-•
Code.) p 011- `l lil,._i!
WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS ERIAL � J
OR A MIXTURE CONTAINING.A HAZARDOUS MATERIAL EQUAL TO OR GREATER T AN THE
*tProfesSions
as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY •
tensed contractors to construct the project (Section 7044, jj
- a-9•
Business and Professions Code.) VES El NO❑ (-j€ CS
WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING
OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH - ' .�3-eye•!° 7L-7 y v'}
CONSTRUCTION LENDING` AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR
GUIDELINES. ITEM" ,
I hereby,affirm that there is a construction lending agency for YES❑ No❑ L t! !!
the performance of the work for which this permit is issued(Sec. f! +
the pe CIV.C. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING TOTAL q._ �q3- - 37
j /�i / CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE,
/I,/�� L.Jlh D•-�'`�//��J� TITLE p,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS CHECK �i
m Lender's Name /CI G + ff (((Ill�o� I�h'YI N MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. `.L'-•z 3!r.
Lender's Address q o o cA� y �.!'��lNGE
OWNER OR AGENT
1 certify that I have read this application and state under penalty
CL r .
0 of perjury that.the above information is correct.I agree to comply P.C.FEE �B PERMIT FEE
U) with all county ordinances and State laws relating to building D �� l�lJljl!-{jl j! -2/20/96)m construction, and hereby authorize representatives of this County ISSUANCE FEE s I
toeWer upon the abo e-mentioned property for inspection purposes. of 7 3 0 4916 PM y 2;C0
g ZG .�yrJ C.fv .`/ 1 INVESTIGATION FEE - TOTAL FEE /
N re of cans or ggenl Da�P (a /
SEE'REVERSE FOR EXPLANATORY LANGUAGE